Epilepsy is one of the most common chronic neurological diseases with the prevalence of about one percent.1 The failure rate of treatment with antiepileptic drugs (AED) is 20–30 percent.2 Drug-resistant epilepsy is defined by the International League Against Epilepsy (ILAE) as a failure of adequate trials of two tolerated and appropriately chosen and used AED schedules to achieve sustained seizure freedom.3 Most of the patients with developed drug resistance never become free of seizures with medical treatment alone.4 Benbadis and coworkers report that it takes on average 18 years before patients are referred to an epilepsy centre to consider non-pharmacological treatment.5 Analysis of the trends of epilepsy surgery in the USA demonstrated that surgical procedures in this field are heavily underutilized.6 Therefore, positive attitude of medical personnel towards alternative treatment options is important to patients with drug-resistant epilepsy. The aim of this study was to assess general knowledge of and attitude towards epilepsy surgery among medical students.
Online poll was distributed to all available e-mail addresses of medical students of Faculty of Medicine, University of Ljubljana, Slovenia. Syllabus of Faculty of Medicine Ljubljana lasts six years. In essence, students are introduced to basic science in the first half and they start their clinical rotations in the second half of the study. Neurology is a part of the mandatory curriculum in the fourth year. However, several extra-curriculum neurological or neurology-related activities are available and encouraged by the Faculty of Medicine.
Questionnaire was short with the first part consisting of two questions of general knowledge of drug resistant epilepsy, followed by questions of students’ attitude towards epilepsy surgery and referral of patients, ending it with demographic questions. The survey was opened 72 hours. Full questionnaire is available in Supplementary Table 1. All incomplete surveys were excluded from the study.
General statistics of the results were produced. Students were divided according to their level of study. The Chi-square test was used for statistical analysis of differences between variables. A p-value of < 0.05 was considered significant. Statistical analysis was carried out using PSPP ver. 0.9.0 (GNU; Free Software Foundation, Boston, MA, USA).
Most of the responses came in within the first 24 hours. In 72 hours, 325 completed questionnaires were received. Detailed demographic data is shown in Table 1. Sex, level of study and age can be observed (Table 1).
Most of the students reported that they were familiar with the term “drug-resistant epilepsy” (72.3%), however, their knowledge of the term “mesial temporal sclerosis” was poor in 85.8% of cases. Students answered that they were aware of possible surgical treatment of some cases of epilepsy (74.5%) and that they generally would have supported an operation (48.9%). Only 2 students answered that they would not have encouraged a patient to undergo an operation. As the most common referral option for a patient with drug-resistant epilepsy, students chose a general neurologist (76.6%). However, 19.4% would have referred a patient to a specialized Centre for Adult Epilepsy. Full responses are listed in Table 2.
When knowledge and referral patterns were compared to the level of study, general knowledge of epilepsy surgery was better in higher levels of study (p < 0.001). Moreover, awareness of surgical treatment of epilepsy was also better in the last years of study (p < 0.001). However, the association of choice of referral and the level of study was not statistically significant (p = 0.66). Detailed analysis is shown in Table 3.
Results of this study are encouraging and generally show a positive attitude of medical students in our sample group towards epilepsy surgery. As shown in Table 2, most of the participants answered that they were aware of drug resistance among patients with epilepsy (72.3%) and that surgical treatment for some types of epilepsy was available (74.5%). However, students reported lack of knowledge of the term “mesial temporal sclerosis” in 85.8 percent. Even though not all patients with mesial temporal sclerosis (MTS) have epilepsy or drug-resistant epilepsy,7 MTS is one of the most common pathologies encountered among patients suitable for epilepsy surgery.8 This outcome was expected since regular medical education does not provide all the details of this specific field to the students. However, detailed knowledge was not essential for a positive attitude towards epilepsy surgery, since 48.9% of students expressed support for a surgical procedure. Moreover, just a few students would have disagreed with an eventual operation (0.6%). However, 50.5% of students were indecisive and they admitted their lack of knowledge of this topic. The authors believe that attention should be focused on epilepsy surgery role and benefits to patients with drug-resistant epilepsy.
If students were put in the position of a general physician treating a patient with refractory epilepsy, most of them would have referred a patient to a regular neurologist (76.6%). Depending on organization of health services in a region or a country, a patient could visit a general neurologist that is not an epilepsy expert. The importance of advocating that a patient with drug-resistant epilepsy must be referred to an epilepsy centre may be seen in American studies of review of trends of epilepsy procedures between 1990 and 2008. They found an increase in patient admittance, especially in small centres, however an increase in operations was not observed. Several explanations were offered: higher number of unsuitable candidates for surgery, novel AEDs and the inexperience of small hospitals. Therefore, more challenging lobectomies were not performed as often.6 A similar situation was observed in the United Kingdom where a decrease in procedures was noted with the exception of vagus nerve stimulation implantations.9 Jehi and coworkers reported a negative trend of medial temporal lobe epilepsy-related surgery. That might be due to increase of extratemporal resections,10 however the general recommendation in the professional community still advocates treating refractory epilepsy in highly specialized centres. Hakimi and coworkers proposed that a lack of communication between referring neurologist and an epileptologist in a specialized centre negatively impacted referring physician’s views on epilepsy surgery.11 In our study only 19.4% of students would refer a patient to the Centre for Adult Epilepsy, which is the only highly specialized centre in Slovenia. Since we tested the population of medical students, it is impossible to conclude that general physicians themselves are not informed enough and therefore they may be the cause of wrong referrals and delaying the patients. Nonetheless, authors recommend more attention is already paid to this issue in the process of undergraduate education.
Higher level of study affects knowledge of epilepsy surgery (p < 0.001). That can be explained by the fact that students are introduced to neurology in the fourth year of the curriculum at our faculty. However, the authors want to emphasize that better knowledge in the last years of study might also be due to involving students in extra-curricular activity, such as accompanying patients to the surgical treatment at the University Hospital Erlangen, Germany, working in long-term epilepsy monitoring units during nights and weekends in our centre and including students in clinical research work. We believe that practical experience is worth more than theoretical knowledge, therefore we would like to encourage other universities to offer opportunities to students to gain insight into patients’ problems as well as diagnostic and treatment options.
To our best knowledge, a study of knowledge of epilepsy surgery among medical students has not yet been performed. Recently, a study of knowledge of epilepsy among medical students was performed in Turkey.12 Authors did not focus on epilepsy surgery per se, however 25.2% of students chose brain surgery as a possible treatment of epilepsy. In another study among Swedish neurologists,13 results showed general positive attitude in favor of epilepsy surgery, with extremely high opinion about the cost efficiency of the treatment (92%). Interestingly, most of the neurologists tried out three or more anti-epileptic drugs before considering surgery (82.1%), which may be considered too long and shows a hesitation despite a general preference for epilepsy surgery. Italian14 researchers found a better attitude towards surgery in a group of consultants in the field of neurology than among other neurologists, pointing out the lack of experience and relevant data in the latter group. In Canada, nationwide research was performed15 and almost half of neurologists incorrectly defined drug-resistant epilepsy. The above mentioned studies involving medical doctors are not directly translatable to our research setting. However, they might offer some reasons responsible for un-derutilization of epilepsy surgery.
In conclusion, the study shows that general awareness of epilepsy surgery among students of Faculty of Medicine, University of Ljubljana is very good. This study found inadequate referral decisions of medical student and indecisiveness of students due to lack of knowledge of epilepsy surgery. We welcome the activity of the ILAE and other societies for their worldwide contribution. Moreover, we also encourage all institutions involved in medical education to highlight the importance of epilepsy surgery in improving seizures and quality of life.4